Provider Demographics
NPI:1417573676
Name:LICON, CHLOE IVANA (LMFT)
Entity Type:Individual
Prefix:
First Name:CHLOE
Middle Name:IVANA
Last Name:LICON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36330 HIDDEN SPRINGS RD STE E
Mailing Address - Street 2:
Mailing Address - City:WILDOMAR
Mailing Address - State:CA
Mailing Address - Zip Code:92595-5804
Mailing Address - Country:US
Mailing Address - Phone:951-200-3402
Mailing Address - Fax:
Practice Address - Street 1:36330 HIDDEN SPRINGS RD STE E
Practice Address - Street 2:
Practice Address - City:WILDOMAR
Practice Address - State:CA
Practice Address - Zip Code:92595-5804
Practice Address - Country:US
Practice Address - Phone:951-200-3402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-23
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist